Madeleine House

Updated 3 March 2021

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

As part of CQC's response to the coronavirus pandemic we are looking at the preparedness of care homes in relation to infection prevention and control. This was a targeted inspection looking at the infection control and prevention measures the provider has in place.

This inspection took place on 23 February 2021 and was announced.

Updated 3 March 2021

This unannounced inspection took place on 20 November 2018. At the last inspection on 05 and 07 September 2017, breaches of legal requirements were found. This was because the provider’s processes were not consistently effective at identifying shortfalls when monitoring the quality of the service relating to the welfare of people.

Madeleine House is a care home registered to accommodate up to 41 people, some of which were living with dementia. The home also provides short stay interim beds (EAB) for people discharged from hospital, who may require further assessment of their care and support needs before returning to their own home or another care home. Madeleine House is a purpose-built home with bedrooms situated across two levels with lift access to the first floor. At the time of our inspection 40 people were living at the home. People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided and both were looked at during this inspection.

There was a registered manager in post at the time of the inspection. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At our previous inspection in September 2017, we had rated the service under the key questions is the service safe, effective, caring, responsive and well-led as ‘requires improvement’ and found they were not meeting fundamental standards. At this inspection, there had been sufficient improvements to improve the rating to ‘good’.

People were protected from the risk of abuse and avoidable harm because staff knew what action to take and the provider had safeguarding systems and processes in place to keep people safe. People were supported by sufficient numbers of staff who were kind and respectful and had the knowledge they required to care for people safely. The provider’s recruitment processes were robust and ensured the necessary security checks were completed to make sure persons employed by the provider were safe and appropriate to provide care and support to people living at the home. People received support from staff to take their prescribed medicines. Systems and processes were in place to ensure medicines were managed safely and only staff who had undergone training were permitted to administer medicines.

Staff received supervision and appraisals, providing them with the appropriate support to carry out their roles.

People and their relatives were involved as much as practicably possible alongside healthcare professionals, to ensure that any decisions made in respect of their care and support needs, were done so within their best interest’s and in accordance with the Mental Capacity Act 2005.

Where people were assessed to lack the capacity to consent to the support they received, the provider followed key processes to ensure the care being provided was in the least restrictive way possible. Applications had been made to safeguard people against the unlawful deprivation of their liberty, where necessary. People’s privacy, dignity and independence were respected.

People were supported to maintain a healthy diet with choices of different foods available and all their health needs were met with the support from staff and healthcare professionals. Staff knew people well and people felt they received care and support from staff that had the skills to meet their needs. There was a complaints process in place and where there had been complaints, these had been addressed. Appropriate action had been taken to reduce risk of reoccurrences. People and relatives were complimentary about the management and staff.

People were relaxed and were supported by staff and the management team to maintain relationships that were important to them. There were activities that provided opportunities to optimise people’s social and stimulation requirements. The home was in the process of implementing a programme of change to the environment to ensure it was more ‘dementia friendly.’

People and relatives had received satisfaction questionnaires to comment on the quality of the service being delivered. Everyone spoken with told us they would not hesitate in recommending Madeleine House to others.

Systems in place to monitor and improve the quality of the service had improved to ensure people received a good and continually improving quality of service.